For clients

Your sleep questionnaire

Bought a package? Wonderful — tell us all about your little one's sleep so your consultant can prepare your personalised plan before you talk.

0 – 18 months 18 months – 5 years Pre-natal

Sleep Questionnaire — 18 months to 5 years

General

Select Package *

Which consultant would you like to work with? *

Where do you live? *

Email *

Phone Number *

What is your child’s name? *

Age and date of birth of your child? *

Names of parents and any other caregivers? *

Name and age of any siblings? *

Are there any health concerns? *

Is your child on any medication? *

Does your child have any food allergies or sensitivities? * Yes No Other

Other

How would you rate your child’s eating habits? (picky eater, healthy appetite, only eats the same 5 things..) * Picky eater Healthy appetite Only eat 5 foods Other

Other

How much juice or milk does your child consume in a day? *

What is for breakfast, snacks, lunch, dinner and treats? *

What time is dinner? *

Does your child have any snacks right before bed? If so, what? *

Are there any developmental delays or concerns about your child? *

Sleep Questions

What time does your child start the day? * 5am 6am 7am 8am Later

Other

Does your child snore or is he/she a heavy mouth breather? * Yes No Other

What happens when he/she wakes up in the morning? (Feeding, play, cuddles, breakfast) *

Where does your child sleep, and do they share a room with anyone? * Sleep in his/her own bed in their own room Sleep in his/her own bed in our room Sleep in our bed then moved to his/her own room Sleep in our bed all night Sleep wherever they fall asleep

On a scale of one to ten, with ten being extremely dark, how dark is your child’s room at bedtime and through the night? (1 being the lightest, 10 being darkest) * 1 2 3 4 5 6 7 8 9 10

Where and when does your child watch TV? * In the living room in the evenings In the living room any time of day In the living room before bed time In the living room but not before bed time In our room anytime of day My child does not watch TV

Where and when does your child play on any other sorts of electronic devices? * Everyday anytime he/she wants to Everyday anytime he/she want to but with limits

Does your child ever take a daytime nap? If so, when and where? How long is the nap? *

What time do you start the bedtime routine? *

What are the steps of the routine? *

What is the scenario when your child is falling asleep? * Every night is different We prepare the room, prepare the bath and plan ahead We try to plan ahead but have no routine Other

Other

What time is he/she actually asleep? *

What happens throughout the night? Best and worst-case scenarios? *

Was there a time when your child did sleep well, and things changed? *

What are the most frustrating or difficult issues for you around your child’s current sleep habits? * He/she is crying at bedtime He/she does not want to fall asleep on his/her own He/she does not sleep through the night He/she wakes at night He/she throw tantrums at bedtime We dont have many frustrations

What would be your number 1 sleep goal? * For my child to sleep through the night For us to have a well rested night For us to successfully have a bedtime routine

Has your family experienced any major life changes or traumas that could be affecting your child? *

Is there a family history of depression or anxiety disorders? *

Are there any concerns or worries about getting your child sleep well? *

Is everyone in the household committed to seeing your child sleep well and on his/her own? * Yes No Other

Other

Is there anything else you’d like to share with me that you think I should know before we meet? *

Thanks for getting this back to me, and I look forward to our meeting! All the best, Marijke Coetser

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